By Bruce Hiley-Young,
L.C.S.W. and Ellen T. Gerrity, Ph.D.

NCP Clinical Quarterly
4(2): Spring 1994

The significance of critical incident stress debriefing (CISD) to the fields
of traumatic stress and emergency response is evident in its worldwide
application (e.g., the International Foundation for CISD), its extended use to
individuals other than emergency response personnel (1-6), and its recent
incorporation into disaster counseling projects and the American Red Cross
disaster mental health training program (7). Originally developed to mitigate
stress responses among emergency first responders (8), the growing use of these
protocols with victims of community-wide disasters deserves scrutiny. As
respondents to disasters who have conducted more than seventy-five community
debriefings for the Federal Emergency Management Agency (FEMA), for the
Department of Veterans Affairs, for the American Red Cross, California Office of
Emergency Services, and for disaster crisis counseling projects, we recognize
that CISD procedures may help some disaster victims. We are concerned, however,
that an unreasonable expectation of CISD usefulness may be developing among
field practitioners. In this article, we propose that important differences
exist between a "critical incident" and a community-wide disaster, and draw
attention to clinical issues related to CISD and questions that await study.

CISD is a generic label applied to a variety of group process protocols used
in a variety of settings, with a variety of groups, and is often carried out by
practitioners trained briefly in CISD. Usually, CISD is a facilitator-led group
process conducted soon after a traumatic event with individuals considered to be
under stress from trauma exposure. When structured, the process usually (but not
always) consists of seven steps: Introduction; Fact Phase; Thought Phase;
Reaction Phase; Symptom Phase; Teaching Phase; and Re-entry Phase. During the
group process, participants are encouraged to describe their experience of the
incident and its aftermath, followed by a didactic presentation on common stress
reactions and stress management. The rationale given for this process is that
providing early intervention, involving opportunities for catharsis and to
verbalize trauma, structure, group support, and peer support are therapeutic
factors leading to recovery (9).

CISD is used increasingly with individuals and in settings outside the normal
emergency response sites (such as emergency rooms, and police or rescue
stations), and is now being used with victims and providers of all kinds (e.g.,
teachers, clergy, victims, etc.), and in a wide range of settings (such as
schools, community disaster field offices, churches, etc.). However, it is
likely that not all disasters should be approached in the same manner. There are
important differences between a "critical incident" and a community-wide
disaster. Unlike most critical incidents (such as shootings, on-the-job
accidents, etc.), community-wide disasters involve the political, cultural, and
economic past of an affected community. These historical factors converge
with the disaster itself (the number of deaths, physical and systemic
destruction, relief and recovery efforts, etc.)to shape the
future of the community and the individuals who live there (for detailed
discussion on how disasters affect communities, see 10-16). Another difference
is that the complex aftermath of community-wide disasters is characterized by
newly arising stressors. In addition to the stress of trauma exposure and the
initial losses incurred (e.g., loss of loved ones, friends, and/or property),
the stress response of a survivor may be influenced by resulting problems with
unemployment, financial resources, substance abuse, marital and family discord,
or mental health problems, as well as disaster-related organizational politics
involving safety, rebuilding, and relocating.

The lifetime and current prevalence rates of PTSD (9%) and adult psychiatric
disorder (48%) suggest that many disaster victims need to address traumatic
reactivation or pre-existing mental disorders (17-18). For example, an
earthquake victim who has successfully readjusted following an earlier sexual
assault may begin to re-experience intrusive thoughts or nightmares about the
assault. Though this victim/survivor may benefit from understanding how the
effects of these two events may be related, CISD protocols are not designed to
accommodate this relationship. The anticipated therapeutic benefit of
"universalization," that is, learning that one's reactions are common to other
debriefing participants, may not occur in the case of the unwitting grouping of
victims who are in different stages of adaptation (19) or in cases of traumatic
reactivation (for detailed discussion of the treatment of disaster victims
experiencing traumatic reactivation, see 20). Moreover, the National
Co-morbidity Survey (18) found that the majority of people in the United States
with mental illness never receive treatment. As many as one in four disaster
victims may have a history of untreated mental illness, thus further questioning
the usefulness of focusing solely on the "critical incident." In sum, CISD may
provide some immediate opportunities for victims to talk with one another, but
is unlikely to provide effective treatment for complex, ongoing, or persistent
problems that are the result of the disaster itself, pre-disaster
vulnerabilities, or the variety of social conditions that surround it.

Short term group discussion is, however, an opportunity to educate. The
intent of the teaching is to normalize reactions, facilitate coping, increase
awareness of adaptive and maladaptive behaviors, "spot" and refer individuals
who may benefit from specialized assistance, and provide information about
related community resources. Typically, the conventional teaching phase of CISD
addresses common stress reactions and stress management. We recommend expanding
the range of educational topics to include the complex factors associated with
stress reactions. An overview of recommended topics is presented in Table
1).

3. Stress-related disorders (PTSD; disorders which
may be exacerbated by stress)

4. Parenting guidelines (how to enhance children's
coping)

5. Disaster preparedness

6. Characteristics of the disaster environment
(phases of disaster)

7. When and where to seek professional help

Are debriefings effective with disaster victims? Case reports and anecdotal
evidence of debriefing suggest that they may indeed lead to symptom mitigation
(9); however, there has not been rigorous, controlled investigation to date. The
lack of data on the effectiveness of CISD present significant intervention
risks, particularly with unknown or unassessed victims/participants, as is often
the case in the provision of disaster mental health services. Recent reviews
(21, 22) of the empirical evidence for the efficacy of a range of PTSD
treatments (i.e., pharmacotherapy, behavior therapy, cognitive therapy,
psychodynamic and hypnotherapies) indicate that certain procedures may be
well-suited to one individual but not another, and that certain treatments may
be more suitable for certain symptoms. This may also be the case in
interventions for non-pathological stress reactions. Salient clinical issues
such as intervention timing, short and long-term effects, victim-intervention
matching, individual vs. group treatment, contraindications, pre-morbidity,
etc., need further study.

Clearly, disaster helpers cannot wait for definitive proof of the efficacy of
their efforts. In general, programmatic and therapeutic interventions typically
develop from anecdotal evidence and we acknowledge that the difficulties in
studying disaster protocols are numerous (for detailed discussion of practical,
conceptual, and methodological issues, see 23). While it is true that
psychoeducational intervention may help some disaster victims, we caution
against the unquestioned acceptance of CISD debriefing procedures as a
sufficient intervention following community-wide disasters. We propose that
debriefing be viewed within its function to address a limited aspect of victims'
disaster experience, that it serve as a means to educate participants about
other critical factors affecting stress response, and that it be a means to make
referrals to other related resources. Lastly, we recommend that other
education-oriented interventions (e.g., outreach presentations to organizations,
institutions, self-help groups, and special populations, media programs, hot
lines, etc.) and efforts to mobilize and strengthen social networks receive
equal effort by disaster mental health practitioners.

Bruce Hiley-Young is
Disaster Outreach Coordinator, National Center for PTSD, Clinical Laboratory and
Education Division. Bruce has worked as a debriefer for the Federal Emergency
Management Agency (FEMA) and California Office of Emergency Services, disaster
counseling projects, as a volunteer for the American Red Cross Disaster Mental
Health Services. and as a disaster services grant reviewer for the National
Institute of Mental Health (NIMH). Ellen Gerrity is Chief of Emergency Research
(including war, disaster, and sexual assault research) in the Violence and
Traumatic Stress Research Branch, at NIMH. Ellen is also an experienced mental
health/disaster researcher, and has worked as a reviewer and consultant to the
American Red Cross and the Center for Mental Health Services (CMHS)/FEMA
emergency mental health services grant program.

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